With the luxury of time, equipment, space, and modern technology, your patient assessment will and should be quite complete. Doc Grouch will focus on the fancy; here we’ll get to the down and dirty. When your patient has a specific, obvious problem (a gunshot wound, or say, anaphylaxis) you don’t have to waste time trying to determine the diagnosis as it’s pretty obvious. You instead focus on the specific problem at hand and look for the common things that come along with that problem.
Documenting a patient assessment is all about mnemonics. The more you learn about anything medical, the more you realize how little you know and how much more there is out there to learn. To that end, every little trick, tip, and method to cheat and be easier on your brain should be employed. As the old saying goes, “If you ain’t cheatin’, you ain’t tryin’.”
CLINICAL NOTE: Before we go any further, let me just say that the method for documenting an assessment and treatment I’m going to cover is A method, but by no means is it THE method. There are lots of ways to do this, and all ways have their strengths and drawbacks. I am covering this one because I use it all the time in the pre-hospital setting and has worked well for me through the years. Use whatever system you’ve used with success in your experience. The key here is to try and make sure that if you are part of a group or team, that you train the same way and use the same protocols to reduce opportunities for Mr. Murphy to take command of the scene. Repetition is the mastery of skill, so the more you use whatever, the better you will be.
A patient assessment – or history and physical examination – is an interview process between you and your patient. Always keep in mind that your patient is a human being and depending on his mindset and the nature of his illness, he may be anxious and in need of reassurance [look up: White Coat Hypertension]. To that end, empathy, compassion, and confidence on your part will go a long way to getting the best answers from your patient to make a field or differential diagnosis. Before you perform any diagnostic test, procedure, or simple inspection and palpation, do your best explain to the patient what you are going to do, why you are doing it, and get his consent to do so. Not all situations will allow for this, but it’s good practice to do it whenever you can.
Also keep in mind that approximately 80% of communication is nonverbal cues like body language and inflection. Be thoughtful of how you are acting and also cue in on what the patient is doing as well.
We’re going to look at the SOAP method of documenting a patient assessment and treatment plan. SOAP stands for Subjective, Objective, Assessment, and Plan. Let’s break it down.
The subjective phase is where you want to establish the patient’s chief complaint (CC) and the history of his present illness (HPI). There is a lot of interviewing here with the emphasis on listening to your patient. Let his answers guide your questioning so you can determine what the affected body parts or systems affected by illness or injury. There’s a hand little mnemonic that you can use called “OPQRST” to help you get an idea from your patient (or bystanders) as to what is going on. For example, let’s say you are responding to a patient with chest pain. Here’s how you can roll through it:
Once you’ve established your general impression, done your MARCH or ABCDE assessments and have a general idea of the patient’s condition and priority, start asking some questions.
General questions: “What’s going on today? Are you not feeling well? Where does it hurt?”
- Onset: “How long ago did it start?” “Has this ever happened before?” This will help you determine acuity and morbidity. If the pain started 20 minutes ago versus two days ago versus two weeks ago, it’s going to help you start figuring out how bad things are. If this is the fifth time this guy has had this happen, he may be able to guide you through the whole treatment process. If it’s brand new, then it could get interesting.
- Provocation / palliation: “What makes it feel better? Does anything make it feel worse?” Remember the old joke,”Hey Doc, it hurts whenever I move my arm.” Doc,”then stop moving your arm.” That’s sort of it, but with less joking and more assessing and documentation.
- Quality: “What kind of pain is it?” This is one where you may have to lead the patient a little by including qualifiers like; burning, tearing, throbbing, penetrating, etc.
- Radiation: “Is the pain located just here or does it go anywhere else?” This is a key question in many medical situations, because pain radiation or referral is a great tool to help with your differential diagnoses.
- Severity: “How bad is the pain? On a scale of zero to ten, with zero being no pain at all and ten being the worst pain in your life, how would you rate it?” Truth be told, I hate that question. If anything, this question is all about observing the nonverbal signals from your patient. If he’s grimacing, sweaty, speaking in short, choppy sentences full of profanity while clutching his chest with his right hand, this brother is in pain. If he calmly looks at you and says “Ten out of ten, and skip the morphine. I need Dilauded with Phenergan to keep from puking” with a BP of 110/68, HR of 68, and SPO2 of 98% on room air, your field diagnosis may be that he is FOS. Use those eyes and ears to help determine what’s happening.
- Time: This one often gets confused with Onset. Whereas Onset determines when the chief complaint started, use Time to determine if the complaint is intermittent or constant, and if there have been any changes in the complaint since its onset. So you might ask your patient, “you said the pain started twenty minutes ago, how does it feel now?”
If the Subjective section is all about what the patient and/or bystanders tell you about the chief complaint, Objective is all about what you record as what you see using all of your medical skills and knowledge. We’re starting to move from opinions to facts. It’s not that opinions are out entirely, as your diagnostic skills will lead to your opinion on the situation, it’s a little more informed opinion because of your medical training. Here you will document what you found in your assessments (Rapid Trauma I & II).
In your assessment, you used your abilities to see (inspect), feel (palpate), tap (percussion), and listen (auscultate – especially when you are using a stethoscope).
If your patient is conscious, alert, and oriented, you’ll want to get a SAMPLE history from him, and if not from him, at least someone that knows him. It works as follows:
- Signs and symptoms: You can plug in the chief complaint, general impression, OPQRST assessment, and things that you yourself see here.
- Allergies: What medications, foods, and environmental factors is the patient allergic to? This is very important to document.
- Medications: What medications – prescription and over-the-counter – is the patient taking. Don’t be afraid to ask about supplements, either. This is also where you want to find out if the patient is taking any undocumented pharmaceuticals from an undocumented pharmacist, even if the chief complaint is unrelated. Cokeheads can have heart problems, too, so remain tactful, empathetic, and focus on treating the patient. Save the value judgements in private for after the call.
- Past / pertinent medical history: What are any chronic health issues the patient may currently have as well as any major illnesses, traumas, surgeries he may have had in the past. Many times the medication list gives up the ghost on what could be ailing the patient, but this helps you really get the picture.
- Last oral intake: What are the last things the patient ate and/or drank. Any substance of any kind, we need to know.
- Events leading up to the present illness: This is important in order to understand the nature of the illness. Let’s use the chest pain patient as an example. We have the following possibilities.
- Patient was sitting in his tree stand on a hunt and all the sudden he had excruciating, crushing substernal chest pain. Could be a heart attack.
- Patient was doing a Tabata interval workout and had transient substernal chest pain that resolved itself when he stopped the workout and rested for ten minutes. Could be stable angina brought on by overtaxing the heart and some coronary artery disease.
- Patient was snorting lines of cocaine off of a stripper’s bottom and has crushing, substernal chest pain. Could be Prinzmetal’s angina brought on by coronary artery constriction from the sympathetic nervous system response cocaine induces.
- Patient was fighting in a bar and is reporting chest pain after someone stabbed him with an ice pick
As you can see, knowing what was happening before the chief complaint presented itself is going to guide your thinking and treatment plans.
During the assessments / examinations to find and stop life threats, you gathered very basic vital signs by confirming airway patency, observing work of breathing and respiratory rate, palpating pulses at the radial and/or carotid arteries, and getting your AVPU, you now need to get baseline vital signs and repeat them every five to fifteen minutes based on the patient’s condition. Tracking vital signs will help you get in front of anything that might be developing in the patient.
Now, depending on where you work and what you do, what exactly constitutes vital signs is going to vary. For this exercise, we’re going to concentrate on the pre-hospital vital signs.
1. Level of consciousness: This is the measure of the patient’s mental acuity. Once you’ve established the AVPU, it’s good practice to use a tool like the Glasgow Coma Scale (GCS) to dial in the severity of the patient’s condition. A GCS of 13-15 is good-ish, 9-12 is not good, and 3-8 is bad. Understand that a dead person has a GCS of 3, and it’s the other vital signs that dial in that condition for you. The key on this is to continually assess your patient and see if he is going up or down the scale, because your treatment plan is going to get very aggressive very quickly if he going down. If you don’t use it every day, it’s easy to forget it, so always have a cheater on hand. Here’s a handy, printable chart:
2. Blood glucose level (BGL), normal range 80-120mg/dL: I list this as number two because it is VERY closely related to number one. A patient that is mentally altered may have a blood glucose derangement, and it is therefore important to know sooner rather than later if your patient is altered because he is diabetic, hypoglycemic, or if there is something else going on.
3. Heart rate (HR), normal adult range 60-100 beats per minute (BPM): Your patient’s general health can have a big impact on this, so it’s important in your assessment to know if your patient has any conditions that would make his heart rate abnormal in number, but normal for his condition.
4. Respiratory rate (RR), normal adult range 12-20 breaths per minute (BPM): Same as above applies. Also notice the patient’s work of breathing and use of accessory muscles to help with breathing. A guy that’s irritated with life and breathing 22/m and a guy breathing at 22/m who is blue and whose neck is getting sucked in with each wheezing breath are very different animals.
5. Blood pressure (BP), normal adult 120/80: This one you have to be careful with because everything from your mood to how much coffee you drank will affect it. It is very important to get a good SAMPLE history from your patient, so again you know what’s “normal” for him. Serial measurements are the best way to do blood pressure. Always observe how your patient is doing and treat the patient, not the measurement. If his BP is sky-high and he has blurred vision, headache, dizziness, and ringing ears, you may have a hypertensive crisis on your hands. If his BP is high because he broke his tibia and fibula and is in excruciating pain, that’s a different story. Treat the wound and the pain, and the BP will drop.
6. Skin temperature, moisture, and color, normal adult, warm, dry, and pink: The skin, or integumentary system, tells you a lot about the patient’s condition. There are many responses that your body has to different medical conditions that cause the skin to get hot or cold, super dry or super sweaty (diaphoretic), and look red, blue, gray, ashen, yellow, and even some other colors. It is important to note those findings with each examination you do.
7. Pulse oximetry (SPO2), normal adult 95-100%: This is a “nice to have” vital sign. It is a measurement of the saturation of a blood protein called hemoglobin (Hgb) with oxygen (O2). Hemoglobin is the main transporter of oxygen in the blood, so if the SPO2 value is low, it can indicate poor tissue perfusion and /or low blood oxygen (hypoxemia) in your patient. You use a small device called a pulse oximeter, which is placed on a fingertip or earlobe, and shoots an infrared light into the tissue to estimate the O2 saturation of the Hgb. Again, this is a “nice to have.” Pulse oximetry can be thrown off by a cold day, a patient with poor circulation (like the elderly), and someone with carbon monoxide (CO) poisoning, since Hgb loves CO 250 times more than O2, and can return false high readings. Furthermore, SPO2 can be unreliable in a situation where there is a ventilation / perfusion mismatch (aka V/Q mismatch) where there is air moving in and out of the lungs, but there is disrupted cellular respiration happening because something is preventing the gas exchange of CO2 and O2 at the alveoli / capillary membrane in the lungs. A pulmonary embolism is a good example of what can cause a V/Q mismatch. If you are flying a patient around in a helicopter, the SPO2 can appear to drop because of the flickering effect of the rotors spinning overhead, so again, treat the patient, not the numbers.
The body systems
Finally you are going to note what you found when you examined the patient from head to toe.
- General impression
- Head, ears, eyes, nose, throat
- Lower extremities
- Upper extremities
You’ll also want to document pertinent negatives. These are signs and symptoms that you would expect to find with the patient’s chief complaint, but aren’t there.
If our chest pain patient was normotensive, had normal respirations, had warm, pink, dry skin, a HR of 72, SPO2 of 99% on room air, and a 12-lead EKG that was completely normal, we’d call these pertinent negatives, because we’d expect him to be hypo or hypertensive, have pale, cool, and sweaty (diaphoretic) skin, an abnormal heart rate, and some signs on the EKG of ischemia. He could still be having a heart attack, but you need to think through what else could be causing his condition.
This is where you start to move from metrics to what is called a differential diagnosis. In most cases, field providers are NOT providing the definitive diagnosis. They are going to list the most likely conditions the patient has and treat the most life threatening and/or likely one according to protocols. The definitive diagnosis is going to happen at the site where definitive care will be given.
So let’s again go to Mr. Chest Pain. Now let’s put his vital signs at HR 122/m, RR 28/m and labored, BP 158/108, SPO2 93% on room air, BGL 88mg/dL. Let’s also say he has a past history of high cholesterol, hypertension, and smokes a pack a day.
His differential diagnosis would be (at a minimum):
- Myocardial infarction (MI aka heart attack)
- Pulmonary embolism (PE – blood clot in the pulmonary arteries)
- Dissecting aorta
- Spontaneous pneumothorax
Once I have my prioritized list, then I develop what my diagnostic and treatment plan will be.
CLINICAL NOTE: Many providers, like paramedics, operate under a set of protocols and procedures that are developed by an MD a team of MDs, Doctors of Osteopathy (DO), and/or all of the above. The protocols tend to be algorithms that guide the medic through his assessment based on patient presentation and history. As he works through the algorithm, differential diagnoses and treatment plans with proscribed skills and medication doses are “pre-loaded” so that he can treat based on what his assessment reveals. This is what’s known as offline medical control or standing orders because it enables the field provider to treat the patient without having to contact an advanced provider for guidance. If the field provider finds the patient presenting with something that goes outside of the protocol, he can get on the radio and contact the attending physician at the receiving facility and seek online medical control, where the MD provides guidance on the differential diagnosis and treatment plan. In this situation, the medic better have great assessment, documentation, and communication skills, because he is trying to paint a picture of a patient’s condition over a radio to an MD at a busy facility that may be twenty minutes away. If the treatment plan deviates from the protocol, he’ll need online medical control to get the OK to do it.
This is where you outline the steps you are going to take to better diagnose and treat your patient’s symptoms in priority. The key components are:
- Diagnostic plan: specific tests to confirm or rule out the differential diagnosis or drive further examination.
- Therapeutic plan: steps to alleviate the patient’s symptoms, not necessarily focusing on patient comfort, but outcomes to keep him alive
The SOF medical handbook also includes a Rehabilitation plan and Patient/Family education plan. I am leaving these out because they tend not to be part of pre-hospital care. In grid-down medicine, they very well may be key items, because you may be the best medical help someone can get for some time, so don’t ignore them (like I just did).
Again, in the case of Mr. Chest Pain, the Diagnostic and Therapeutic Plans in the pre-hospital setting may look like this.
* Note: “q” means “every” or “each.” So q5 minutes means every 5 minutes.
- Place patient on basic cardiac monitor
- Place patient on 100% O2 via nasal cannula at 4lpm (100% oxygen at four liters per minute using a nasal cannula)
- Conduct a 12, 15, or 18-lead electrocardiogram (EKG) to identify myocardial ischemia or infarction q5 minutes until PT is hemodynamically stable or chest pain resolves, then q15 minutes
- 324mg ASA PO (324mg of chewable aspirin – an anti-platelet drug that prevents further blood platelet aggregation – given orally)
- Place two 18ga IVs in left and right antecubital fossae (the veins at the bends of the elbows) with PRN adapters (these allow the clinician to swap out IV lines as well as administer medicines intravenously without disturbing the IV catheter)
- Start a 500mL NS drip KVO (a 500mL bag of 0.9% normal saline at a drip rate of Keep Vein Open)
- 0.4mg NTG tablet SL x 3 q5 minutes or until chest pain resolves and PT is hemodynamically stable (0.4mg of a dissolving tablet of nitroglycerin – a vasodilator – given under the tongue every five minutes until the patient’s chest pain goes away, his vitals are normal, and his EKG shows resolution of ischemia)
- 4mg MS (morphine sulfate – pain control and vasodilator) IV then 2mg q5 minutes up to 10mg total until PT is hemodynamically stable and pain resolves
- NTG paste .5 – 2 inches on left anterior chest if chest pain unresolved (a ribbon of nitroglycerin paste – a vasodilator – from a small tube approximately .5-2″ long applied to the skin on the left front chest)
- Rapid transport to Percutaneous Coronary Intervention center for further diagnostic and definitive care
- Reassess PT q5 minutes
In more advanced settings, the plan may include checking Troponin levels (a cardiac enzyme that is released by the heart during ischemia and infarction), administration of more anti-platelet drugs like Plavix, administration of beta-blockers, a cardiac ultrasound, possibly even the administration of t-PA (tissue plasminogen reactivator), a clot-busting drug, as well as cardiac catheterization, also known as Percutaneous Coronary Intervention (PCI).
The Rehabilitation plan would be what the patient’s primary care physician and / or cardiologist may prescribe to get him out of the hospital and back home.
The Patient / Family education plan is going to include rare advice like; stop smoking, eat better, move more, get your cholesterol and blood pressure under control.
Wrapping it up
To do a good assessment, you better know your anatomy, physiology and pathophysiology, so be sure to check out Doc Grouch’s posts to get your basics down and your chops up. You also need to practice, practice, practice. The more with living people the better. Even if it’s scenarios for a while, the more you see “normal” the easier it is to see “abnormal” when it presents itself.
Good documentation and a good patient report are the keys to a chain of great patient care when you have to change shifts or transfer patient care to another clinician. Furthermore, good documentation will buttress you in court if – heaven forbid – you ever get invited to go there to testify in a case where your medical treatment is part of the discussion. Lawyers will pick every word you write apart, so it’s important that you master this skill.
If you use the iPad or any kind or Android, the Wilderness Medical Institute has an excellent app for documenting using the SOAP methodology.
They also have excellent downloadable paper SOAP note templates you can print out and practice with.
If you have some money burning a hole in your pocket, there is a really great simulator app on iPad and Android called Resuscitation. If I am not mistaken, the initial download is free with limited cases, and then you buy “cases” that are geared towards different levels of clinicians. The levels include Paramedic, ER MD, OB/GYN, Pediatrics, and Neurology (be careful not to buy the cases for the UK, they’ll mess with your head). You simulate assessing and treating a patient, then perform both differential and definitive diagnoses. After that, your performance is graded and there is a write up of the case, usually by an MD that is a specialist in a certain area. The write up is where the science is dropped, HARD, so read them. It’s a great brain trainer and much cooler than Candy Crush or Angry Birds.
For helping with coming up with a differential diagnosis, look up your state’s Office of Emergency Medical Services and see if they have a downloadable protocol book (H/T to pa4ortho for this idea). These are great learning tools and are also great brain trainers. Here’s a link to the North Carolina protocols as an example. They’re pretty good.
Print out the NOLS SOAP Note template. Grab a buddy, even better a significant other, and do the whole rapid trauma assessment as we have reviewed over this series of posts. Document what you find, even if everything is normal.
Then have your “patient” go run around the block or do pushups until failure. Do the assessment again and document what you find.
1. United States Special Operations Command. (2001). Clinical Process. Special Operations Forces Medical Handbook. (pp. 2-1 – 2-5). Retrieved from https://www.dropbox.com/s/2b4rgh3irny27t5/SOF_Medical_Handbook.pdf?dl=0
2. Bledsoe, B.E., Porter, R.S., Cherry, R.A. (2009). Documentation. Paramedic care, Principles and practice. (pp. 288-311). Upper Saddle River, NJ: Pearson Prentice Hall
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